Reporting on Health's Bill Heisel has a fascinating two part interview (part one, part two) with Tracie McMillan author of The American Way of Eating: Undercover at Walmart, Applebee’s, Farm Fields and the Dinner Table.

Thursday, March 29, 2012

In case you missed the news, two recent studies (here and here) published in the New England Journal of Medicine demonstrated dramatic superiority of surgery over intensive medical management in the treatment of type 2 diabetes.

Now I'm not going to get into the studies here and dissect them for you, but I think that they were well done studies, and while admittedly we still don't know what their long, long, term benefit will be, at 2 years out, they look damn good with surgery coming out worlds better than "intensive medical therapy" for the treatment (and remission in many cases) of type 2 diabetes.

Of course time's definitely a fair concern. Meaning what if 5 or 10 years down the road the folks who had the surgery are no better off than those on medical therapy? Thing is, based on what we know already about the surgeries involved, all have well known 5 year data, and the bypasses and diversions much longer than that, and those studies, while they weren't specifically designed to look at diabetes alone, did look at weight and medical comorbidity regains, and I certainly don't recall anything that suggested diabetes returned with a vengeance.

So basically here we have a surgical intervention that is dramatically better than a medical one, for a condition that causes cumulative damage and can wreak havoc on a person's quality and quantity of life.

Yet many MDs, allied health professionals and health reporters, including some who I know, respect, and admire, are taking this opportunity to discuss how we shouldn't be looking to surgical solutions for diabetes because patients could instead use their forks and feet. While there's no argument about the fact that in a ideal world everyone would take it upon themselves to live the healthiest lives possible, there's two problems with that argument. Firstly, not everyone is interested in changing their lifestyle, and secondly, statistically speaking, the majority of even those who are interested and successful with lifestyle change will ultimately regress - the simple fact remains that we don't yet have a proven, reproducible and sustainable approach to lifestyle change.

And what of those folks not wanting to change? I say, "so what?". Since when did MDs, allied health professionals or health columnists earn the right to judge others on their abilities or desires to change? Our job is to provide patients with information - all information - including information on lifestyle change, medical management and surgery. We can even provide patients with our opinions as to which road we think may be best for them, and why, but honestly, given the results from these studies, I'm not sure how anyone could make an evidence based case that surgery isn't a very real and powerful option that ought to be discussed with all of their obese or overweight type 2 diabetics.

Unless of course that someone has some form of weight (or simply anti-surgery) bias.

Let me give you another example. Let's say there was a surgical procedure that folks with breast cancer could undergo that would reduce their risk of breast cancer recurrence by roughly 30%. Do you think anyone would question a woman's desire to have it? I can't imagine. And yet lifestyle - weight loss and exercise has indeed been shown to reduce risk of breast cancer recurrence by 30%. Think people would dare suggest the women choosing surgery were, "taking the easy way out", that they should just use their forks and feet?

We've got to get over ourselves.

Until we have a proven, remotely comparable, reproducible, sustainable, non-surgical option, if you bash the surgical option on its surface for being "easy", or "wrong", you might want to do a bit of soul searching as to whether or not you're practicing good medical caution, or if instead you're practicing plain, old, irrational bias.

[and for new readers to ensure there's no confusion - I'm not a surgeon]

Wednesday, March 28, 2012

I'm sure you've come across this phenomenon before. Some almost slim person who was just barely medically definable as overweight loses 20lbs and suddenly is an expert at preventative public health policies and obesity treatment and prevention. They take their n=1 experience with minor weight loss and decide that whatever worked for them ought to work for everyone, and that clearly the solution to society's weight woes is easy, because hey, if they can do it, so can anyone.

It's a strange and all too common phenomenon. It'd be like folks who just finished their first piano lesson preaching about what it takes to become a concert pianist, or for an Easy Bake baker to speak with authority about the intricacies of baking croissants, souffles and French macarons.

Take for example Jessica Allen. She's an associate editor with Maclean's magazine (Canada's answer to TIME), and she recently penned an opinion piece entitled,

"When it comes to being fat, we’re simply too polite"

In it she details how in response to her physician's, "stink eye", that she lost 20lbs over a 5 month period. And of course, because it worked for her she wonders,

"If we can’t count on our doctors to call the kettle fat, then who can we count on?"

Ms. Allen, I'm sure you mean well with your post, but if you truly believe that what's missing for those who struggle with weight is personal desire and a sense of personal responsibility, and that what's required to help those same people is name calling and shame, then sadly all it really demonstrates is that you don't in fact have a grasp on what it is to struggle with weight, nor an understanding of weight's complex etiology.

Yes, I know, if you eat less and exercise more you'll lose weight, and yes, in your case if you lay off your frozen dinners and get back to your running you may lose the 25% of weight you regained. That said, do you honestly believe that there's a deficit of desire among those with weight to lose, a desire whose flame is simply not being lit by their doctors who for some odd reason don't believe in negative reinforcement?

So forgive me Ms. Allen, if I don't practice my stink eye, for if guilt, shame and name calling were useful in the generalized real world, then the real world would most assuredly be one hell of a skinny place as it currently has no shortage of guilt, shame and name calling for those with obesity.

Katherine Hepburn famously said of her slim physique: "What you see before you is the result of a lifetime of chocolate." New evidence suggests she may have been right.

Beatrice Golomb, MD, PhD, associate professor in the Department of Medicine at the University of California, San Diego, and colleagues present new findings that may overturn the major objection to regular chocolate consumption: that it makes people fat. The study, showing that adults who eat chocolate on a regular basis are actually thinner that those who don't, will be published online in the Archives of Internal Medicine on March 26.

The authors dared to hypothesizethat modest, regular chocolate consumption might be calorie-neutral –in other words, that the metabolic benefits of eating modest amounts of chocolate might lead to reduced fat deposition per calorie and approximately offset the added calories (thus rendering frequent, though modest, chocolate consumption neutral with regard to weight). To assess this hypothesis, the researchers examined dietary and other information provided by approximately 1000 adult men and women from San Diego, for whom weight and height had been measured.

The UC San Diego findings were even more favorable than the researchers conjectured. They found that adults who ate chocolate on more days a week were actually thinner – i.e. had a lower body mass index – than those who ate chocolate less often. The size of the effect was modest but the effect was "significant" –larger than could be explained by chance. This was despite the fact that those who ate chocolate more often did not eat fewer calories (they ate more), nor did they exercise more. Indeed, no differences in behaviors were identified that might explain the finding as a difference in calories taken in versus calories expended.

"Our findings appear to add to a body of information suggesting that the composition of calories, not just the number of them, matters for determining their ultimate impact on weight," said Golomb. "In the case of chocolate, this is good news –both for those who have a regular chocolate habit, and those who may wish to start one."

Holy awesomesauce batman! Eat chocolate, get thinner! If you're not eating it already, maybe you should! Chocolate is a magic fairy food that has unknown substances that not only cause chocolate's calories not to count, but actually makes chocolate a net negative calorically!

Only they're not, and they don't, and there is no growing "body of evidence" suggesting there are magically calorie neutral or negative foods (though there are certainly differences indirectly consequent to different foods' impacts upon satiety).

The study looked at 975 men and women aged 20-85 who filled out a single food frequency questionnaire as part of their enrollment in a study that was meant to look at the non-cardiac impact of statin drugs. Included in the questionnaire was the question, "How many times a week do you consume chocolate?". The authors then looked at the relationship between chocolate frequency and BMI controlling for:

Fruit and vegetable intake

Saturated fat intake

Mood

Number of days of week active for at least 20 minutes.

That's it, that's all? Nothing else?

Ummmmm, last time I checked people ate more than just chocolate, fruits, vegetables and butter.

Honestly I seem to recall reading or learning somewhere, maybe it was in med school, that people sometimes eat things like beef, fish, chicken, nuts, lentils, pulses, dairy products, and candy. Oh, and don't they also sometimes have breads, pastas, and cereals? And does anyone other than me drink alcohol?

Would how much they ate or drank of those things matter in a study looking at their weights?

And do you think a question like, "How much chocolate do you consume?", would have been helpful in assessing its effect? And are the only non-food related variables that affect weight mood and exercise? How about maybe controlling for medications and medical conditions that affect weight, socio-economic status, education, sleep duration, marital status, smoking, etc., those other pesky things that have been shown to actually impact upon BMI?

Here's part of the authors' conclusions from the paper,

"The connection of higher chocolate consumption frequency to lower BMI is opposite to associations presumed based on calories alone, but concordant with a growing body of literature suggesting that the character - as well as the quantity - of calories has an impact on metabolic syndrome factors"

Really? A growing body of literature suggests that there are foods whose calories don't count? I notice that there are no actual references provided for that particular statement.

So to recount - basically here we have a study with no controls whatsoever rendering conclusions impossible, authors who rather than mention their study's pretty much insurmountable methodological limitations instead made up a "growing body of literature" on magic calorie neutral or negative foods, a press release that spins it all as fact and as a result, as of early this morning, less than 24 hours after publication, there were already 443 chocolate makes you thin stories on the newswire to further misinform an already nutritionally confused world.

Once again I'm left scratching my head trying to understand how this could possibly have made it to - let alone passed - peer review, and why it is that ethics and accuracy don't seem to matter to the folks who write press releases, or to the respected researchers who are drawing these unbelievably irresponsible and over-reaching conclusions despite undoubtedly knowing better. It also makes me wonder just how exactly they all manage to sleep at night.

[Even more amazing? This study was NOT funded by the chocolate industry]

The study was quite straightforward. Measure the blood pressure in both arms of patients, follow patients for nearly 10 years, and then see if there was any relationship between between arm blood pressure differences and morbidity and mortality.

The results were rather striking, and probably the easiest way to report them is to state that in patients without known cardiovascular disease, having a between arm difference of 10mm Hg or more in their systolic blood pressure (the top number) and having some risk for cardiovascular disease, conferred as much (and perhaps more, but not statistically significantly more) risk to 10 year survival as did having known pre-established cardiovascular disease.

The authors recommend that patients with marked inter-arm differences be managed more aggressively, and while there's not yet data suggesting benefit, it's a compelling study and subsequent to its early publication, I've begun measuring blood pressure bilaterally and have had a few patients who've had large inter-arm variances.

Secondly there's cuff size.

If the cuff's too small, you'll get a falsely high blood pressure reading. Watch your doctor put on the cuff to ensure proper sizing - there's usually a guide on the cuff itself where two parallel lines need to cross to ensure proper fit (you can see them in the picture below). Alternatively when your doctor's putting on the cuff, ask him or her how size is determined!

Lastly there's temper.

If you've been waiting in the waiting room forever and you're upset, it's not impossible your pressure's up as a consequence. I'd hate to see you placed on blood pressure meds because your doctor runs chronically late. If you suspect that your blood pressure's up only when you see your doctor (due to "white coat" or "waiting room" hypertension), consider buying a home blood pressure cuff to monitor on your own. Just bring your home cuff with when you see your doctor so that you can validate your cuff's reading against your doctor's (and they can also check to ensure you're putting it on properly).

I'm not sure there's any food or nutrient on the planet where the benefits of its consumption would make cutting it with 9.75 teaspoons of sugar worthwhile, and truly wonder whether if the choice were between serving no breakfast and serving this drek, if serving no breakfast wouldn't be the better option.

What do you think?

[Just for fun, did a bit of math. If you gave your kid one of these a day for a year, they'd consume just over 31 pounds of breakfast sugar, just over half a 5lb bag a month]

Wednesday, March 21, 2012

Kid (with whiny voice): "Mo-om, I don't like milk!"
Mom: "Ok honey. How about I make it taste better?"
Kid: "What do you mean?"
Mom: "Watch"

Mom then measures out 3 teaspoons of sugar, dumps them one by one into the milk and stirs.

Kid: "Awesome!"

Sounds crazy, no?

And yet it's happening in kitchens the world over due to the combination of great marketing from the folks at Nesquick (who have currently partnered up with Disney and have licensed their Phineas and Ferb characters to sell chocolate syrup) along with the belief that there's a milk/calcium emergency out there that's so bad that it's wiser to add 3 teaspoons of sugar to every glass of your kids' milk (the amount in a serving of Nesquick syrup) than to have them drink less of it.

It's the they don't like fruit so we'd better feed them pie phenomenon.

"acknowledges that good health can best be realized independent from considerations of size. It supports people—of all sizes—in addressing health directly by adopting healthy behaviors."

And truly, I could not agree more in that the words "healthy", and "weight", are not mutually inclusive or exclusive terms.

According to HAES' founder Linda Bacon, one of HAES' tenets is, "Show me the data", and in her recent Huffington Post piece, she says that we should all be demanding the data too and adopting HAES' "more skeptical" mantra.

Again, I could not agree more.

Yet despite readily agreeing that fat has been regularly and unfairly vilified by society and the medical community for decades if not centuries, and despite regularly telling my otherwise healthy overweight and moderately obese patients that their weights aren't likely contributing much if anything to them in the way of medical risk, I struggle with HAES as it would seem to me that they are fighting misinformation with misinformation, and in so doing, weakening and cheapening their incredibly important and valuable message.

"- Stable fat is blown out of proportion as a health risk (even dreaded "tummy fat"), but yo-yoing weights common to dieters do harm health.

- The "ironclad" notion that obesity leads to early death is wrong: Mortality data show "overweight" people, on average, live longest, and moderately "obese" people have similar longevity to those at weights deemed "normal" and advisable.

- Life spans have lengthened almost in lockstep with waistlines over the last few decades, which should make you wonder about the supposed deadliness of fat."

If we're talking, "show me the data", then lets talk data. First, the data on yo-yo diets, otherwise known as weight cycling. Looking at the most recent and robust data, one set from than Cancer Prevention Study II Nutrition Cohort which followed 55,983 men and 66,655 women from 1992-2008, and the other set from the Nurses Health Study which followed 44,882 women from 1972-1994, neither demonstrated any relationship between weight cycling and mortality. Other studies have exonerated weight cycling from increasing the risk of hypertension, and type 2 diabetes, and there's a mixed bag of studies suggesting both protective and causal effects of weight cycling on various forms of cancer. But if we're really talking "show me the data", the only thing very conclusively linked to weight cycling are increased body fat percentages, and while I definitely agree weight cycling is symptomatic of a broken societal approach to weight management, and may well carry with it some harm, the data simply do not currently support a blanket, "harm health" statement.

Next the "ironclad" comment. While it's true that "overweight" has been shown to be protective in the over 65 population, and that "Class I", or "moderate", obesity carries the same risks as "normal" weight in that same population, what Linda omits here, other than the age qualifiers, is the ironclad fact that as weights rise more dramatically than simply "moderate" obesity, so too does risk. And it's not just as weights rise, but also as weight responsive conditions accumulate as is clearly shown by Dr. Sharma's Edmonton Obesity Staging System work which demonstrates that as EOSS stage rises, where EOSS evaluates weight in the context of having or not having weight related co-morbidities or quality of life impacts, so too does mortality.

Lastly we get to the lockstep comment about the last few decades. Here I'm nearly at a loss for words. Is Dr. Bacon honestly suggesting that the very simple fact that our life spans are continuing to lengthen, while at the same time as a society we're gaining weight, is in turn an argument that weight can't possibly be deadly? Isn't the whole point of HAES' existence to combat what HAES sees as correlations not being causal? Couldn't there be dozens, if not hundreds of other explanations for why our life spans are increasing despite our weight gains even if those gains did carry risk? Like for instance the very dramatic improvements in medicine that have occurred over the course of the past few decades?

Fighting misinformation with misinformation, relevant omissions with relevant omissions, and logical fallacies with logical fallacies, is not the way to accredit your movement, and if HAES has any hope of actually penetrating mainstream medicine, something I would dearly love to see happen, they're going to need to hold themselves up to at least the same, if not a higher level of scrutiny to which they hold others. If they don't do so, then their detractors will have an easy time dismissing them as champions of a self-serving, non-evidence based, over-hyped agenda, which ironically is the very same thing of which HAES is accusing mainstream medicine.

Monday, March 19, 2012

The short version of what it told me was that the BMJ is actively and willfully abusing the public's trust, and it also told me that many low-carb and paleo diet guru bloggers and tweeps don't care about bad nutritional epidemiology so long as it vilifies carbs.

Here's the longer version starting with the BMJ.

Last week the BMJ published another observational dietary study out of Harvard. This time the study's focus was on white rice and it involved a meta-analysis of the medical literature on white rice consumption and its impact upon the risk of developing type 2 diabetes.

According to the study's authors, prior studies on white rice and type 2 diabetes had mixed results, and so in order to try to illuminate them, they undertook a literature review. In the end the authors' exclusion criteria left them with only 4 studies detailing 7 separate cohort analyses. Follow ups in these cohorts ranged from 4 to 22 years, and of them, 2 had exceedingly low incidences of type 2 diabetes development and so the authors had to perform some statistical sleight of hand to include them.

Of the 7 cohort analyses, 2 did not control for differences in dietary consumption patterns (probably important if you're looking at the impact of dietary factors on diabetes development), 1 did not control for family history of diabetes, 6 did not control for income/socioeconomic status, and none controlled for consumption of other refined grains or sugars. Let me go over that last one again not one of their 7 cohort analyses controlled for consumption patterns of refined grains or added sugars (though 2 controlled for consumption of "bread" and "noodles" but these weren't broken down any further).

Pooling the data together led researchers to a relative risk of type 2 diabetes development of 1.27 for the highest white rice consumption with a 95% confidence interval possessing significant heterogeneity and starting at 1.04, which for the non-statisticians reading this means the finding is just barely interesting.

When the researchers then stratified the data by ethnicity they found that for Asian populations the pooled relative risk was 1.55 with a confidence interval starting at 1.2, and for Western populations a pooled relative risk of 1.12 with confidence intervals ranging from 0.94-1.33, meaning that according to their findings, the impact of white rice on diabetes risk only seems to exist in Asians.

Translation?

The most generous way I can spin it would be that this study, using pooled cohorts that left out tremendously important controls and considerations, when analyzed, suggested that white rice consumption increases the risk of diabetes development in Asian, but not Western, populations.

The worst way to spin it? The fact the cohorts used to determine this study's conclusions failed to consider incredibly relevant diabetes confounders like family history of diabetes, socioeconomic status, and dietary consumption patterns, including the dietary consumption of other categories of refined grains, makes quantifying the effect on diabetes development due to white rice consumption from this data set impossible.

And yet it was published in the BMJ?

But that's not the truly shocking part. This is. The BMJ published an accompanying editorial that rightly called the paper out on its methodological and statistical inadequacies and in conclusion stated,

"Although the findings of the current study are interesting they have few immediate implications for doctors, patients, or public health services and cannot support large scale action. Further research is needed to develop and substantiate the research hypothesis"

Yet what's the title and first line of the very same BMJ's press release regarding this statistically and methodologically weak paper,

"White Rice Increases Risk of Type 2 Diabetes

The risk of type 2 diabetes is significantly increased if white rice is eaten regularly, claims a study published today on bmj.com."

Where the next 6 paragraphs of the press release continue in that same conclusive and important sounding vein only to end with this last line,

"In an accompanying editorial, Dr Bruce Neal from the University of Sydney suggests that more, bigger studies are needed to substantiate the research hypothesis that white rice increases the chances of getting type 2 diabetes."

And of course the Twitterverse went crazy too and rice bashing tweets abounded, and from some rather influential tweeps including Dr. Sanjiv Chopra, Dean of Continuing Education at Harvard Medical School, the Harvard School of Public Health itself, journalist Greta Van Susteren, the American Society of Nephrology, the Drudge Report, and many, many, many, many more.

Now I'm not suggesting white rice is a wise food to consume. On the contrary, I generally recommend people try to minimize its consumption, but to be very clear, this study does not in any formative way, shape or form have the strength to draw any conclusions whatsoever on the specific impact white rice has on the risk of developing type 2 diabetes.

And what the hell is up with the BMJ? Publish a paper so weak that you feel the need to co-publish an editorial questioning the paper's design and conclusions and then simultaneously put out a press release that in turn purposely glosses over and misinforms the media about the paper's weak conclusions?

And lastly, where is the low-carb and paleo bloggers' and tweeps' outrage? We saw it surge like never before when a far more rigorously controlled and designed observational study on red meat came out just a week before, and yet here there's pretty much critical silence (Zoe Harcombe being a notable exception). There were even examples where prominent low-carb and paleo folks retweeted the press releases to their followers as if they were facts, when just days before those very same tweeps were tweeting their outrage at what they saw as the meat study's undeserved promotion.

Friday, March 16, 2012

Today's Funny Friday video has an acronym in it, "PMO". For my non-Canadian readers it stands for Prime Minister's Office, but rest assured, you don't need to be Canadian to find this both sad and funny.

In fact I'd venture that my American readers may find it both sadder and funnier as I'm guessing it's an American formulation of Scientist Pest Control that we've started spraying here in Canada.

Thursday, March 15, 2012

The problem with the statement isn't that it's not true, it's that it often paralyzes true change.

The thing is behaviours are pretty complex things, and so if you've got a highly complex system and change one variable, well you might not really expect to see much in the way of change.

When it comes to lifestyle relatable chronic disease, I do believe we're in a jam. Health care costs are climbing rapidly and I'd wager dietary quality is continuing to fall while physical activity sure isn't rising.

If we apply the belief that for every action comes and equal and opposite reaction to the complexities involved in dietary or fitness behaviours and look for quantifiable outcomes from each and every singular intervention then I think we're screwed because those behaviours are cloaked in far too much complexity to have simple, singular, solutions. Instead, if we're really serious about the need for change, we need to layer intervention on top of intervention, even if in and of themselves each individual intervention doesn't seem to accomplish very much.

What we have to come to terms with is that there won't be any simple solutions. There won't be any shortcuts. There may even be unintended negative consequences, but we as a society need a complete and total overhaul of our dietary value systems, our paces of living as they pertain to health, the leveling of the playing field between the consumer and the food industry, and more, and we need to accept the fact that the road to better health, while there, is shrouded with tremendous uncertainty despite the simple truisms of energy balance.

Of course if we park the car simply because we can't see around the next bend, we're never going to get anywhere, and so long as we keep moving, even if we take a few wrong turns, we might even get where we're trying to go.

Wednesday, March 14, 2012

According to the authors, their study was undertaken because prior studies demonstrating risk to red meat consumption were flawed. Some had utilized populations that weren't representative of the average, while others didn't differentiate between unprocessed and processed meats, and where others still had covariates assessed at baseline only.

Here the authors analyzed 28 and 22 years of data respectively (2.96 million person years) from the Nurses Health Study and the Healthy Professionals Follow Up Study involving 37,698 men and 83,644 women who were free of cardiovascular disease and cancer at baseline, and whose diets were assessed by 7 sequential (every 2-4 years) validated food frequency questionnaires. Given dietary recall difficulties, undoubtedly the questionnaires are from from perfect, however unlike the vast majority of other food/risk studies that utilize them (there's not a huge amount of choice but to do so), the data from the questionnaires here were adjusted using the correlation coefficients that separate and published validity analyses (here and here) of their own specific study population's food frequency questionnaires determined were required to at least try to account for their subjects' dietary recall inaccuracies.

The authors also controlled for the following potentially confounding variables:

Age

Body mass index

Ethnicity (though this was weak, white or non white were the only two choices)

Smoking status (never, past, current with current being subdivided into 3 quantities)

When analyzing the data they discovered that men and women with higher intakes of red meat were less likely to be physically active and were more likely to be current smokers, to drink alcohol, to have a higher body mass index, to consume greater total amounts of calories and to have lower intakes of whole grains, fruits and vegetables, but even after controlling for all of those confounders, unprocessed and processed red meat consumption were found to be associated with an increased risk of total mortality, cardiovascular mortality and cancer mortality.

So are you going to die if you eat red meat?

Well you're going to die regardless of what you eat, but this study would suggest that you'll die ever so slightly younger if you eat red meat each and every day of the week, and even younger still if you eat processed red meat each and every day of the week. Did you catch the caveat of each and every day of the week? It certainly wasn't hidden in the study.

So how much younger will you die? According to the study, eat unprocessed red meat daily and your risk of death will be 13% higher than if you don't. Eat processed meat daily and it'll be 20% higher. Those of course are relative risks. In absolute terms your risk of dying younger due to red or processed meat consumption doesn't amount to a huge number, nor do the study authors sensationalize their paper to suggest that it does. The media (and perhaps the study's press release - haven't seen it) did that. But that doesn't change the finding that this study did indeed determine there to be more risk associated to red meat consumption than other protein sources.

As to what it is about red meat that's seems to confer risk? We don't know. Meta-analyses on saturated fat would suggest that ain't it, and that's good news for us butter lovers, but again, that doesn't change this study's findings.

All in all this is a strong study in that there's an incredible wealth of data along with tremendous confounder controls and considerations. We'll never have perfect studies regarding foods and risks because we'll never randomize folks to long term diets differing in single variables and so studies like this one - long term, huge numbers, confounder controlled, thoughtfully considered - are the best we're going to get, and while I'm sure there are variables some axe grinders will wish were included, or analyses they'd love to have seen, to me at least it seems they included all the big ticket issues, and some smaller ticket ones for good measure.

If there's criticism to be had it's in the study's reporting, where the distinction of eating red or processed meat daily is lost in the hype, and where the reporting leaves readers thinking they can never safely enjoy a burger, a steak or a hot dog.

That's certainly not what the study or its authors said. In fact one of the authors, Harvard's Frank Hu stated,

"A moderate consumption, for example one serving every other day, I think is fine."

While the study's lead author An Pan told the LA Times whose headline ran, "All Red Meat is Bad For You" that he eats two servings of red meat a week.

And this isn't really news. Basically the study's take home message is that proteins come in both healthy and unhealthy packaging.

And that's where my Internet confusion comes in. Just as ridiculous as the all encompassing, "All Meat is Bad" chant that came from the mass media was the, "this study is terrible" chant of the Internet, a chant generally coming from those same people who will readily agree that there are less and more healthful carbohydrates (and fats). Seems to me a careful read of the paper would have perhaps toned down both the media's reporting and the Internet's rhetoric, whereas relying on press releases and newspaper reports, well that fuels misinformation, and apparently in this case, what comes off like frank anger.

I adore red meat. I also adore processed red meat. But ultimately this study just adds more weight to what the bulk of the literature has already concluded - processed and unprocessed red meats aren't my best protein choices and if consumed daily, carry risks, albeit absolutely small ones, that other protein sources seemingly don't.

Now maybe my read of the paper is off, and admittedly my stats days are long behind me so please feel free after actually reading the paper to weigh in if you think I've missed something, but for me, for now, yes, burgers are still on my menu this weekend (Mmmmmm, burgers), they're just not on it every day this week.

Tuesday, March 13, 2012

Today's guest post comes from our office's RD Mark McGill who has a few things to say about nutrition month here in Canada.

He was rather horrified to receive his marketing materials for the month given what he felt to be a rather blatant bias. Interestingly, last week 3 other RDs approached me to ask if I would write about what seems to have become "Milk Month".

Every February, since I’ve been a Dietitians of Canada (DC) member, I’ve received a triangular shaped cardboard poster-box in the mail. It acts a tangible reminder that Nutrition Month (March) is just around the corner. And while the theme varies each year (for 2012: Get the Real Deal on Your Meal: Dietitians Bust Food and Nutrition Myths), the primary goal has been a constant: to educate Canadians on what healthy eating is all about and that their best source for obtaining this information is from a Registered Dietitian. It’s something that Dietitians of Canada works hard to promote and rightfully so as that’s their purpose. From our mission, vision and values which state in part to advance,

"the profession's unique body of knowledge of food and nutrition and that our dealings with colleagues, associates, clients and the public [are to be] based on credibility that relies on information from solid, scientific evidence and direct experience to support decision-making"

and that RDs do this with integrity to ensure we function with honesty, fairness, and objectivity to one of this year’s press released busted "myths",

"There is no difference between a dietitian and a nutritionist."

The answer, in part, states that a dietitian is your smart choice for credible advice on healthy eating.

I’m not going to discuss whether or not I agree with how the myths are answered as fellow RD Diana Chard has already taken care of that quite nicely. Instead, my focus is going to be on the blatant bias and conflict of interest that exists in the materials I was sent. These include a cover letter, a colour poster, two double-sided educational sheets for copy and distribution (one students grade 7 and up, one for adults).

The cover letter was signed by Isabelle Neiderer, RD and Director of Nutrition for Dairy Farmers of Canada (DFC). Since DFC are the National Sponsor for Nutrition Month 2012 (they’ve been a sponsor in previous years, as well), I guess the fact that her name is on it shouldn’t come as a huge surprise, or that she states that in addition to the materials I’ve been sent, I can order copies of a brochure entitled “What’s True? What’s Not? Get the Real Story about Milk Products” or that if I have any questions I can email nutrition@dairynutrition.ca. What would be a surprise is if the material in the package, the brochure or a reply from DFC is "honest, fair and objective" as per the statement on the DC website.

So what's inside? Certainly not "honest, fair and objective".

First there is the student resource entitled "The Myth Buster" which has games and quizzes that aim to shed light on common nutrition myths. Of the 7 crossword puzzle clues, milk's featured in two, which perhaps isn't in and of itself terrible, but clue number 4 is probably worth highlighting,

"4. Chocolate milk has the same _________ as white milk",

where the "correct" answer is "nutrients". Never mind the 15.5 tsp of sugar and 360 calories per 500mL of 1% chocolate milk I suppose.

More amazing though is this statement found at the bottom of that Myth Buster page, entitled, "We're Brilliant,

"Humans may be the only adult mammals that drink the milk of another species. Eating nutrient dense milk products have helped humans survive and thrive all over the world!"

where the answers listed for you consideration are,

"True",

"Very True",

and

"The Truest"

Well just because we can doesn’t mean we should, and while the risks to milk consumption probably aren't particularly high, there is certainly a real body of research that links milk consumption to ovarian cancers and more aggressive forms of prostate cancer, while its benefits to osteoporosis prevention, at least according to the Nurse's Health Study, appear to be non-existent (If you're interested, here's Harvard's take on the subject). And chocolate milk? I think Dr. Freedhoff's covered that pretty well in the past.

Next comes a word scramble. The first question of the word scramble has you sort out the words fattening, yogurt, healthy and less. When finished you get a statement saying it’s a myth that milk products are fattening and that eating them has been associated with a healthy body weight and less body fat. Last time I checked, consuming calorie-dense, higher sugar products (chocolate milk, fruit-on-the-bottom yogurts) contributes to the opposite, and that the data on milk and body weight is at best described as weak, preliminary and under powered, and at worst described as the product of a conflicted researcher who has patented the claim that milk helps with weight loss.

Oh, and hey, how does that answer contrast with this statement,

"Sorry! There is no food that burns fat or makes you lose weight more quickly."

The adult sheet (entitled "Mythmania") is also awash with dairy goodness.

From the section entitled "Milky Madness" which addresses myths such as "milk causes mucous" to the inclusion of dairy in all three included recipes, milk is featured quite prominently. How prominently? Well the handout is meant to present just a smattering of the myths from Milk Month, oops, I mean Nutrition Month's Dietitians of Canada press release. What's telling is the fact that while the Dietitians of Canada's lists 39 myths, only 3 of which involve milk, the handout I've been given by Dietitians of Canada to provide to my adult patients includes 10 myths, 5 of which feature milk.

Finally, there's the poster I've been given to hang up in my office. If you squint your eyes and look hard, you'll find a few sources of protein that aren't dairy. They're up in the top right corner. That's where you'll find the entirety of your non-dairy based protein choices (nuts, beans, meats, and fish). What won't be hard to find? Milk. The giant glass of white milk splashing in the centre, the flavoured yogurts, the 3 huge hunks of cheese, and of course the chocolate milk. There's also a QR code that you can scan. It's also on all of the handouts I'm supposed to be giving my patients. Wanna guess what image you'll see when you get there?

Suffice to say that I have not and will not be using any of these materials and encourage other DC members to do the same. Doing so goes against the principles that as DC members, we are supposed to stand for. If we truly want to be viewed as authoritative voices it is imperative that our messages this month be unbiased and trustworthy. Both of which are impossible given the large corporate influence that currently exists.

Puree ingredients and simmer for a good hour.Add soy sauce to taste, if desired.

Other permitted foods:

Day 1: All fruits except bananas. As much water melon as you like - it has practically no calories.Day 2: As many vegetables as you like, raw or boiled. But no beans, peas or sweet corn.Day 3: Fruit and vegetables, except potatoes and bananas.Day 4: Up to 8 bananas and 8 glasses of milk (max. 1.5% fat) or skimmed milk products.Day 5: Up to 300 g beef, grilled, and 8 tomatoes.Day 6: As many vegetables and as much lean beef as you like. (All vegetables with water removed).Day 7: As much brown rice, vegetables, sugar-free fruit juices as you like. As much black coffee or tea, no sugar, as you like.

If ever you feel peckish:

Back to the soup!

It can be modified and supplemented to suit your own personal needs, forming the basis for a healthy diet.Wishing you every success.

Dr. Klaas

The diet's ridiculous. Both from a nutrition perspective, and from a helpful perspective as any diet that strict risks nutritional deficiencies and guarantees a long long term failure.

Oh, and according to Dr. Wharton who did some snooping, not surprisingly there is no Dr. Klaas at the Toronto General Hospital. There is however an ophthalmologist called Dr. Klass. Guessing he or she isn't related.

Do me and your friends/colleagues a favor. If you've got a blog or a Facebook page, please link to this post. If you've got a Twitter account, please retweet it.

Not because I'm looking for traffic, but the more links made to this posting where the linked words are, "The Toronto General Hospital Diet", the greater the chances it'll wind up as the first thing someone'll find when they Google it. I'm hoping the power of social networks will be enough to quash this traumatic diet for good.

Thursday, March 08, 2012

Firstly we know that posted menu board calories only matter to those who care about calories, and so when a recent study suggests that for all comers it only causes a small, if any, drop in calories ordered, that's not remarkable given pre-order surveys of patrons in New York City suggest that only about 15% of folks currently care.

More importantly though, what no study of menu board calorie impact will ever measure are the calories not ordered by the patrons who decided consequent to menu board calories postings, to eat out in restaurants less frequently and hence weren't included in the study at all.

I have to admit, I get frustrated when I read articles in newspapers like the one by Marni Soupcoff a few days ago that suggest menu board calories aren't worth it. Marni's especially given that the restaurants studied in the paper that led her to her broad sweeping and premature conclusion were in low-income neighbourhoods and as I've argued before, the poor may well value dollars more than they do calories (a fact Marni doesn't mention in her blanket thumbs down to the practice).

And as I mentioned yesterday, there is never going to be a singular intervention that'll do the trick, but that doesn't mean we should scrap the single interventions. Couple menu board calories with better energy balance and nutritional education in schools, public health campaigns surrounding daily caloric needs as well as a call to action to bring back home cooking, the end to crop subsidies that allow fast food to be sold for pennies, an advertising and toy ban for fast food companies targeting children, and hey, maybe we'll see some changes.

So Marni, forgive me if I label your suggestion that menu board labeling is a

"waste of time and money",

as painfully ill informed, and your labeling of the practice of providing consumers with more information at point of purchase as

"a petty exercise of power that puts us one step closer to a public-health police state",

Wednesday, March 07, 2012

In order for any single public health intervention to have an impact on any sort of obesity, it would mean that whatever target the intervention manipulated would have to in and of itself be responsible for a large and significant percentage of the problem.

And therein lies the rub. Our struggle as a society with weight and/or healthy living has more to do with the accumulation of dozens, if not hundreds, of environmental changes where the end result is an environment where the unattended consequence of spontaneously living is weight gain. Simply put, the current pushes us there.

The reason it's important to always keep this in mind is that the likelihood there'll ever be a singular intervention that makes a demonstrable impact is exceedingly low, and that fact is going to bedevil policy makers, researchers and analysts because it's going to be tough for them to make the case, "Yeah, sure, that didn't do much, but we've got to keep doing it anyhow even if there was no demonstrable benefit".

It's that whole twig thing. Effortless to break one. Easy even to break two, three, four, five and more, but get a large pile of small twigs together and eventually you'll get to a point where despite each twig being laughably snappable itself, together they might as well be a log.

Keep that in mind before you pass judgment the next time on the futility of a particular intervention after you read about how a study on intervention "X" didn't seem to make a demonstrable difference on obesity rates, weight changes or eating behaviours.

It's David Katz's single sandbag phenomenon, and if you're surprised that a single sandbag wasn't enough to stop the flood, I think perhaps some remedial Flooding 101 is in order.

"You can imagine my disappointment when I read Tribune reporter Julie Deardorff’s 'Kids who play sports eat more junk food: Study(News, Feb. 24), the second article this month that failed to provide readers with a balanced perspective about the Coca-Cola Co.'s business practices.

To set the record straight, Coca-Cola does not market our beverage brands in venues where children under the age of 12 years are the primary audience. Coke has adhered to this policy for more than 50 years, and it extends to youth sporting events and clubs."

That argument, that Coca-Cola is an upstanding corporate citizen that would never, ever, target kids is one I've covered before, where thanks to the magic of YouTube I was able to quickly pull out 16 different Coca-Cola commercials that in my mind at least, dispute Kevin and Coca-Cola's self-righteous claims of innocence. I also blogged about Coca-Cola's recent "Great Happification" campaign, which if it isn't designed to target kids, then I guess bikini-clad beer commercials also aren't designed to target men.

So according to Kevin, Coca-Cola has a 50 year old policy of not marketing brands in venues where children under the age of 12 are the primary audience, and that the aforementioned policy extends specifically to sporting events. If that's the case Kevin, what do you think went on with the 2011 Vienna City Marathon's literally entitled, "Coca-Cola Kids Challenge" a sporting event where the sole criterion for entry was being younger than 10 years old (photo up above and down below)?

But you know Kevin, let's not nitpick about whether or not Coca-Cola branded sporting events for kids 10 and under are in fact Coca-Cola branded sporting events for kids 10 and under. Instead let me ask you this, if Coca-Cola doesn't market to kids, why does Coca-Cola sell toys?

Looking at Amazon.com's online Toys and Games category there are 719 different Coca-Cola branded toys, including dolls with packaging that clearly states they're for kids aged 3+, 100 piece puzzles aimed at the more sophisticated 5+ crowd, Barbies, stuffed animals, toy cars and more.

Don't branded toys count as marketing?

It's shameful Kevin. Not the fact that your company makes a profit by selling various products, that's the American way, but rather what's shameful is what seems, at least on the surface, as a bald faced lie that Coca-Cola doesn't specifically hold children squarely in their marketing cross hairs.

But maybe I'm confused? Maybe I'm misunderstanding your claim and you've got a way to explain to my readers why I'm out to lunch. If you'd like to make the case that products like the Coca-Cola Kids branded Carmen, where her very packaging suggests the intended audience is aged 3+, along with all the other products posted below, as well as that 10 and under sporting event last year in Vienna, still fit within your company's supposed 50 year promise of not targeting children, please feel free to post a comment.

Monday, March 05, 2012

I've been practicing in obesity medicine exclusively since 2004, have worked with literally thousands of patients and would guess that I've prescribed medication in roughly 0.5% of cases.

So why don't I prescribe meds? Is it because I think people should "Do it the right way", the "old-fashioned way", the "diet and exercise" way? Good god no! It's just that to date the medications that we've had available to us haven't been particularly impressive, where for the most part their side effects weren't worth most people's whiles given the only very modest improvements they provided to weight.

But what if there were a medication that was well tolerated and actually helped the average person taking it lose a medically significant amount of weight? While I'm quite certain I wouldn't use it with each and every patient, certainly if I had a patient who wanted to try it, or a patient where their best efforts weren't affording them further weight loss and the risk or impact of their weight was still significantly greater than the risk or negative impact of the medication, damn right I'd suggest it. Why wouldn't I? That's what doctors do - if there's a therapy where the risks of inaction outweigh the risks of treatment, we discuss treatment.

Now there's something to be said about not trying brand spanking new drugs. Many doctors, myself included, often like to wait for a while once a drug's been released so that if there was a risk or a side effect that the limited sample sizes of Phase 3 clinical trials weren't powerful enough to reveal, we'd learn about it. That caution isn't what I want to chat with you about today. But first, some brief background.

Qnexa is a new weight loss drug that an FDA advisory committee has recently overwhelmingly recommended be approved for use. It's a combination drug that combines a known weight loss medication (phentermine), with a known anti-seizure medication (topiramate). The doses of the drugs used in Qnexa are relatively low compared to their regular usages separately, and perhaps that's why only 16% of the folks prescribed the top dose of Qnexa withdrew from the more than year long study due to adverse effects. As far as weight loss goes, the drug's impressive with an average weight loss of 14.4% of presenting body weight lost by week 56 in one study and 16% in another.

Yes, weight can and does respond to lifestyle changes, but statistically speaking, usually only temporarily. And really, so what? Pretty much everything responds to lifestyle changes including hypertension, diabetes, depression, osteoarthritis, osteoporosis, hyperlipidemia, esophageal reflux, etc., and yet I've never heard a physician suggest it'd be unfortunate if the FDA would approve a new blood pressure medication because upping exercise, losing weight and reducing sodium might do the trick, or because we don't yet know what the impact might be of taking it for a lifetime. And yet that's exactly what Harvard's Dr. Pieter Cohen said about Qnexa,

"It's likely that the FDA will soon approve Qnexa for weight loss. This is unfortunate. Qnexa does help some people lose a modest amount of weight, but to keep the weight off, one has to take Qnexa for a lifetime. But we have no idea if Qnexa is safe to use for a lifetime."

"Assuming Qnexa is approved, what do I recommend? It will be very tempting to try a new diet pill once the FDA gives it their blessing, but in the case of Qnexa: just say no. Stick with the hard work of increasing exercise, modestly decreasing calories and selecting healthy foods"

And Yale's Dr. David Katz, a man I greatly respect and admire, in that same piece had this to say,

"Yes, Qnexa can help you lose weight. But that doesn't mean it will, or even that it should.

Qnexa combines a stimulant drug with an anti-epilepsy drug. The first can drive up blood pressure, and can [cause] jitteriness. The second can cause fatigue, nausea and brain fog. It's not a great drug by any means, and likely only works as long as people keep taking it.

For those facing bariatric surgery, it is an option worth considering, although not as effective. For most others, better use of feet and forks is the far better option."

Honestly, I don't get it. Blindly bashing a drug that's not yet been released because in some cases lifestyle changes might treat the condition, and in other cases because there's the potential for side effects seems insane to me - lifestyle likely has a positive impact on pretty much every condition out there, and every drug ever made has the potential for side effects, and who am I or any doctor to say what each individual's "better" option is?

I'm no pill pusher, and yes, it'd be wonderful if everyone lived incredibly healthy lifestyles, but I think my job as a physician is to ensure people are equipped to make informed decisions, not to make their decisions for them, or to judge the ones that they make. If Qnexa's approved I'll be happy to discuss the medication's pros and cons with each and every suitable patient. I'll also discuss with them the options of forgoing medication in favour of lifestyle changes, of bariatric surgery, and heck, I'll even discuss the option of doing absolutely nothing with them. I'll do it all in a nonjudgmental manner too - because my job is to ensure my patients are aware of the risks and benefits of all of their treatment options, including watchful waiting, and then to support them in whatever informed decision they make. To do otherwise in my mind is contrary to the spirit of medicine and I think, when it comes to Qnexa specifically, it's suggestive of an unfair weight bias that clings to the belief that unless a person is willing to make formative lifestyle changes, they're not worthy of being helped and that if only patients wanted it badly enough, they'd just fix themselves.

In my mind those attitudes are far more toxic than any drug could ever be.

[Full disclosure: I am not a shareholder of Qnexa's parent company Vivus nor am I their paid consultant]

Bonus - watch the video below (email folks, you'll have to visit the blog to watch) and see Dr. Suess' beloved environmental champion trying to sell an SUV. Do you think Theodor Suess Geisel (Dr. Suess) would have approved?

Thursday, March 01, 2012

There's no doubt that one of the most significant drivers of societal weight gain over the decades has been our increasing reliance on eating foods prepared outside of our homes. Couple more frequent meals out with larger portions and certainly that's a recipe for gain for anyone, but an even more dangerous recipe for anyone with an impaired calorie burning ability.

What I mean is that if two folks sit down at a restaurant to eat together, regardless of the differences between those two folks, if they order the same meal, they'll get the same meal. Sedentary 5ft tall middle aged mom with fibromyalgia sitting down to eat with her 6ft 2in College football linebacker son - same order, same meal.

But what if one of those folks burns fewer calories?

There are a great many reasons for someone to burn smaller numbers of calories. Among the most common of those would be advanced age, medications that impair metabolisms, and of course, vertical challenge.

It's a phenomenon that also plays out in households sometimes. I remember somewhere near to when my wife and I were married and she gained a small amount of weight. I wasn't involved in nutrition or weight management at the time, and I only had the most rudimentary understanding of things, but I figured that the crux of the matter was my wife was matching my portions. She told me that she felt she deserved to eat as much as I did, and while I certainly didn't disagree (I've always known better than to ever do that), the simplest way to put it was that yes, she could eat as much as me, but given that the amount of food I was eating supported my weight, my guess was that if she ate the same amount as me, eventually she'd weigh the same too....and I've got quite a few inches of height on her.

At the end of the day, folks with reasons to burn fewer calories, if they're concerned about their weights, understanding and calorie awareness becomes that much more important, as does minimizing meals out because after all, there are no signs on the menu reading,

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About Me

Family doc, Assistant Prof. at the University of Ottawa, Author of The Diet Fix, and founder of Ottawa's non-surgical Bariatric Medical Institute - a multi-disciplinary, ethical, evidence-based nutrition and weight management centre. Nowadays I'm more likely to stop drugs than start them. You can also find me on Twitter and Facebook.

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